Elsevier

The Journal of Pediatrics

Volume 179, December 2016, Pages 74-81.e2
The Journal of Pediatrics

Original Articles
Value of Procalcitonin Measurement for Early Evidence of Severe Bacterial Infections in the Pediatric Intensive Care Unit

https://doi.org/10.1016/j.jpeds.2016.07.045Get rights and content

Objectives

To determine whether peak blood procalcitonin (PCT) measured within 48 hours of pediatric intensive care unit (PICU) admission can differentiate severe bacterial infections from sterile inflammation and viral infection and identify potential subgroups of PICU patients for whom PCT may not have clinical utility.

Study design

This was a retrospective, observational study of 646 critically ill children who had PCT measured within 48 hours of admission to an urban, academic PICU. Patients were stratified into 6 categories by infection status. We compared test characteristics for peak PCT, C-reactive protein (CRP), white blood cell count (WBC), absolute neutrophil count (ANC), and % immature neutrophils. The area under the receiver operating characteristic curve was determined for each biomarker to discriminate bacterial infection.

Results

The area under the receiver operating characteristic curve was similar for PCT (0.73, 95% CI 0.69, 0.77) and CRP (0.75, 95% CI 0.71, 0.79; P = .36), but both outperformed WBC, ANC, and % immature neutrophils (P < .01 for all pairwise comparisons). The combination of PCT and CRP was no better than either PCT or CRP alone. Diagnostic patterns prone to false-positive and false-negative PCT values were identified.

Conclusions

Peak blood PCT measured close to PICU admission was not superior to CRP in differentiating severe bacterial infection from viral illness and sterile inflammation; both PCT and CRP outperformed WBC, ANC, and % immature neutrophils. PCT appeared especially prone to inaccuracies in detecting localized bacterial central nervous system infections or bacterial coinfection in acute viral illness causing respiratory failure.

Section snippets

Methods

We performed a retrospective, observational study of all patients ages 29 days to 21 years admitted to a 55-bed PICU at an academic medical center between August 1, 2012, and February 15, 2014. Patients were included if blood PCT was sent as part of routine care within 48 hours of PICU admission, and the maximum measured PCT within this timeframe was used. For patients with multiple PICU admissions, only data from the first episode were included. We also excluded patients with superficial (ie,

Results

Of the 5521 PICU admissions within the study period, 667 patients met initial inclusion criteria. Twenty-one patients underwent full chart review but subsequently were excluded following determination of noninvasive (superficial) bacterial infections,18 leaving 646 patients for the final analysis (Figure 1; available at www.jpeds.com).

Patients were categorized as having no infection (n = 188), viral infection (n = 162), suspected bacterial infection without shock (n = 89), documented bacterial

Discussion

PCT in critically ill patients is more likely to be used as a guide to discontinue unnecessary empiric antibiotics in the absence of a microbiologically proven bacterial infection than as a diagnostic biomarker to initiate antibiotic therapy. Nonetheless, a clear understanding of the test characteristics of PCT and scenarios prone to false interpretation of results is necessary to optimize use of PCT in critically ill children. In this relatively large study of PCT in critically ill children,

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    Supported by the Division of Critical Care Medicine at The Children's Hospital of Philadelphia. S.W. is supported by National Institute of General Medical Sciences (K23GM110496). The authors declare no conflicts of interest.

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